Lymphoedema services often support patients who are overweight or obese (Provan, 2019). Being overweight or obese are risk factors for the development of lymphoedema and can also be a complication in its management (Provan, 2019). In the UK, clinical efforts to help patients lose weight and keep this weight off have been found to be ineffective (Moffatt et al, 2019; Nymo et al, 2019; Busetto et al, 2021). Studies have indicated that a variety of strategies and approaches successfully lead to weight loss, but evidence shows that the majority of these patients then regain weight (Kouvelioti et al, 2014; Shantavasinkul et al, 2016; van Baak and Mariman, 2019). A common pattern for patients in the author's lymphoedema service is ‘yo-yo’ dieting—moving from one diet to the next, or one approach to the next, losing and then regaining weight. As a result, patients typically become highly demoralised, and this emotional state then sabotages possible future attempts to lose weight. In psychological terms, the experience of repeated failure, ie weight regain, has a serious negative impact on feelings of personal control, to say nothing of the adverse impact on self-esteem (Quinn et al, 2020).
A programme is described here that preceded the COVID-19 pandemic and the enforced restrictions. It arose out of discussions with the local psychology service. It was felt that any weight reduction programme needed to employ sound psychological principles to try and ensure better long-term outcomes. Within public health, it has, for example, been known for decades that well-meaning advice is not usually acted on (Pirotta et al, 2019). People do not cut out junk food because they are told to, do not exercise more because they are told their health will benefit, do not stop smoking because they may develop cancer. A key psychological principle in public health is exploring the barriers to effective change (McVay, 2018). Individual patients often have personal priorities that are very different from those of their nurses or doctors. Unless these are identified and dealt with, patients will not have the resources to act on good advice.
A group programme was decided on (Andreu et al, 2020; Salemonsen et al, 2020; Saul and Gursul, 2021). There are a number of advantages to this approach in terms of efficiencies with staff time. Additionally, this gives patients a chance to become a supportive group, whose members might continue to meet for mutual support after the formal programme has finished. It also provides opportunities for peer learning, as particular individuals may have learned effective ways of dealing with difficult situations that have undermined their efforts to lose weight in the past, for example, dealing with the friend who brings gifts of chocolates. A group format also allows sharing of examples of the homework exercises individuals have practised.
It was decided that the group would meet for a 1.5-2 hour session each week for 6 weeks. A key feature of the programme was that, following the end of the 6 weeks, a 3-monthly follow-up meeting was arranged for the whole group. This was organised because evidence suggests that one key feature of why weight reduction programmes fail is because patients feel abandoned when the group finishes (Coulman et al, 2020; Tolvanen et al, 2021).
The term ‘overweight’ is generally applied to people with a body mass index (BMI) of 25kg/m2 to 29.9kg/m2 and the term ‘obese’ to those with a BMI of 30kg/m2 to 39.9kg/m2. People with a BMI of 40kg/m2 or above are described as ‘severely obese’ (NHS website, 2019).
Group membership
Initially, the author's lymphoedema service ran two pilot groups, with no specific inclusion criteria—eight patients joined the first group and nine joined the second. The groups ran consecutively. Staff used their own judgement about which individual patients on their caseload might benefit from joining such a group. Typically, these were patients who were overweight or obese and whose weight loss had proved refractory to ordinary outpatient support. These were patients from the general caseload of the lymphoedema service. However, there was a very significant drop-out rate in both the pilot groups, with about half of the patients stopping attending after a few sessions. It was therefore decided that, for subsequent intakes, all potential patients for the group would be interviewed by the nurse manager and clinical psychologist to:
- Determine motivation and commitment to respond to six weekly 2-hour sessions and
- To provide patients with a more detailed account of the nature of the group.
At the interviews, the clinical psychologist stressed that the focus of this group was psychological approaches to weight loss and there would be limited dietary advice. One of the reasons given in feedback by a few of the patients for stopping attending the pilot groups was that they had thought they would be getting more advice about diet. At first glance this seemed difficult to understand, because the vast majority of these patients would have had a great deal of advice about diet and would be quite knowledgeable about which foods they could and could not eat. In fact, this may have been a tactful way of explaining why they dropped out of the groups. Staff thought that one of the problems might have been that some patients were uncomfortable with the high levels of distress expressed by some group members who openly talked about very difficult personal circumstances that they were dealing with. Accordingly, part of the interview with possible attendees of future groups indicated clearly that such disclosures could happen, and that group members needed to be comfortable with this. It was stressed that this did not mean that individual patients were under any pressure to disclose personal issues that they did not want to share with other group members.
The procedure of interviewing potential candidates for the group has been successful in reducing the drop-out rate, although a minority of patients do still drop out. For these reasons, staff now commonly start with an intake of 10 patients, expecting a couple to drop out, leaving a group of eight members, which is generally thought to be ideal.
Programme format
It was decided that the group would meet for 2-hour sessions each week for 6 weeks. The group was run jointly by one of the lymphoedema nurses and the clinical psychologist. Patients were weighed before and after the group, and completed Hospital Anxiety and Depression Scale (HADS) self-assessment questionnaires before and after. There is clear evidence of psychological morbidity in obesity (Milaneschi et al, 2019; Chauvet-Gelinier et al, 2019). The expectation was that, if psychological health was improved by membership of the group, then motivation to continue to lose weight and use of effective maintenance strategies would be improved.
During the first session of the group an explanation of the approach that would be followed was given—exploring psychological barriers to effective change. In one study, the most important perceived barriers to weight-loss diets were situational barriers (such as irregular working hours), stress, depression, and food craving; a lack of time and a lack of motivation were found to be barriers to increasing physical activity (Sharifi et al, 2013).
Group members were told that the group leaders were working on the supposition that all participants were almost certainly already extremely knowledgeable about dietary intake and which foods led to weight gain. Invariably, all patients nodded ruefully at this point. The point was then made that most people who had tried to lose weight had experienced repeated efforts that had been successful for a period, only for weight gain to recur. Invariably there was rueful agreement with this statement too. It was emphasised that the group needed to focus on why strategies to lose weight, which had been successful in the past, were no longer employed. The first session then asked all patients to complete a detailed food intake diary.
When completing the food diary, patients were asked to be reasonably precise about the amount of food they were consuming at each point. They were asked to record where they were when eating/drinking, who they were with, and (in one-word descriptors) their mood at the time. This exercise was to help determine patterns to an individual patient's eating habits. It has been found to be a useful way of assessing when and why comfort eating took place (Dunn et al, 2018; Miller-Matero et al, 2019). Comfort eating is a common psychological feature of patients who are obese (Bemanian et al, 2020; Franja et al, 2021); namely they are drawn to unhealthy, high-density food types (Franja et al, 2021). The food diary was also used to explore whether excessive eating was commonly associated with being alone or in particular company. This diary was set as ‘homework’ for participants for that week, but with the message that this now needed to be a continual feature of their daily life. Non-compliance with this (patients commonly stopped doing it after a few days) was good material for group discussion along the lines of research that finds people who successfully lose weight and keep this off are those who persist with effective strategies regardless of present emotional status (McVay et al, 2018; Forman et al, 2019).
In this first session, each patient was asked for their personal weight loss target over the next 6 months. This was to ensure that participants had realistic expectations. They were then told to set this as a goal for themselves, and asked to consider what major reward they would give themselves for achieving their weight-loss target. They were also asked to identify a weekly reward that they could give themselves for successful adherence to the programme. It was interesting to note that many patients found this latter task impossible. This is perhaps a reflection of how demoralised and lacking in self-esteem patients who have become obese are. The group leaders were very firm about insisting on the importance of rewards. Positive reinforcement for success is an elementary psychological principle for maintaining progress (Bolier et al, 2013; Gorlin et al, 2018; Tolvanen et al, 2021).
Patients were also asked to identify someone with whom they could share the fact of their renewed efforts to lose weight; someone who would demonstrably be supportive and give judicious encouragement. This was felt to be critical. Many obese patients end up thoroughly demoralised by repeated failures to lose weight, and are often undermined by those closest to them who belittle further attempts they may make to diet. Much emphasis was placed in this group on the importance of turning a deaf ear to anyone who was like this in their life, while at the same time finding someone who would be supportive. This often worked extremely well, in that many patients then identified a friend or son or daughter who was themselves overweight and, in turn, valued hearing about advice learned in the group.
The second week's session incorporated a mindful eating exercise, in which about 10 minutes was spent looking at, handling, orally exploring, tasting and eating a raisin. It was explained that when people become obese their brain becomes less sensitive to neural impulses from the stomach signalling satiety (Buckland et al, 2019; Yeung and Tadi, 2021). Learning to eat more slowly is a critical part of losing weight effectively. It was suggested that patients put a raisin at the side of each place setting to remind themselves of this.
The third week's session focused on psychological issues in obesity, for example, the tendency to comfort eat to deal with sadness, anger or anxiety. The emphasis here was on learning effective strategies to deal with these emotions without recourse to eating. It was explained that, until other effective strategies became available to the person, they would remain vulnerable to comfort eating. Regular reviewing of patient eating diaries was often informative here, for example, by identifying that patients commonly snacked when bored. The ‘mind bus diffusion technique’ (Keesman, 2018) was taught to patients to help with cognitive diffusion (noticing thoughts rather than acting on them). In this technique, patients are advised to see themselves as a bus driver, and to see various disabling thoughts that they might have, for example thinking they deserved some chocolate as they had had a horrible day, as ‘awkward passengers’, and how, as the driver of the bus, they could deal with these ‘passengers’. The ‘pink elephant’ phenomenon was used to show how we are unable to stop thoughts coming to mind (‘I want you to make every effort, as strongly as you can, not to think about something I mention. Whatever you do, really control yourself and don't think about a pink elephant’). The mind bus diffusion technique is a method of helping people manage thoughts effectively when they do happen. It was stressed to patients that food cravings start off as a thought (‘I need something sweet’), so learning effective ways of managing thoughts is key to managing this situation.
The fourth week involved a session with a dietitian to make sure that there were no gaps in patients' understanding about diet, and also to a physiotherapist who advised about levels of exercise that were within the capabilities of the patients present.
The fifth week reviewed progress to date and suggested ways of practising self control. There is now evidence that exercising self-control/regulation is in some respects similar to undertaking physical exercise that strengthens muscles (Hamdouni, 2022). People who habitually exercise self-control over some matters become better at it. It is important to note, however, that there is a paradox in this, in that exercising self-control can weaken self-control in the short term, so resisting the chocolate bar at 4.00pm can make it more difficult to resist the snack at 8.00pm. The key point remains, however, that exercising self-control does strengthen self-control in the long term. Patients were educated about these principles and sent home with a homework assignment of a task in which they could practise restraint. Patients found this exercise both entertaining but also personally meaningful, and had little difficulty in identifying appropriate exercises.
A major focus of this last fifth meeting was to discuss what the evidence suggests are the key features of people who lose weight and successfully keep it off—that is continued vigilance about weight and maintenance of effective weight management regardless of their present emotional status (Dunn et al, 2018; Miller-Matero et al, 2019). Accordingly, it was suggested that weekly weight checking was appropriate, setting sensible tolerances for this in terms of reasonable fluctuations in weight loss.
The final meeting reviewed progress and re-stated key features. These were the importance of:
- Continuing with the food diary
- Eating slowly
- Keeping their supportive ally ‘on board’
- Dealing with people undermining attempts to lose weight
- Practising effective non-food-related strategies for dealing with difficult emotions
- Breaking bad habits—such as always eating when watching television
- Using cognitive diffusion to deal with unsettling thoughts/cravings
- Practising restraint
- Continuing with weight monitoring.
At the start of each session, patients were asked to talk personally about their progress with homework assignments and lessons learned. This is where the group format came into its own, because other members were able to share strategies that they had found personally effective when, for example, family members were unsupportive or they had eaten because they were bored or ‘fed up’, they had to deal with a friend who insisted on going to restaurants without healthy choice menus, or they had a partner who persisted in piling their plates with food as part of their ‘caring’.
Evaluation
After five groups had been run, a trainee clinical psychologist evaluated the effectiveness of the group. She did a combination of qualitative research through in-depth interviews with participants and a statistical analysis of before and after weight and HADS measures. There was a statistically significant weight loss throughout the duration of the group, but this was not maintained at the 3-month follow-up. Qualitative feedback suggested that patients had not found the group programme long enough. The group had a clear effect on improving the psychological wellbeing of participants. There was, however, a very small sample in this research, and this will have limited the usefulness of the conclusions. All patients were extremely positive about the help that they had received from the group.
Discussion
A group programme with a psychological focus to help overweight and obese patients attending the lymphoedema clinic to reduce their weight was successful in helping patients to lose weight. However, most then regained some weight when the programme finished. This is the problem that bedevils all health service attempts to help such patients. The group was designed with a 3-month follow-up of the patients precisely to try and address this problem. In feedback, patients reported that the 6-week programme was ‘too short’, so clearly a next step is to see whether extending this modestly, to perhaps 10 weeks, would address this problem. The problem, of course, is the availability of clinical staff and time to do this. The group did successfully improve psychological wellbeing, which is an important achievement in that these patients are then likely to be more receptive to and adherent with treatment of their lymphoedema. It is hoped that this article will contribute to understanding in this area.
KEY POINTS
- Many patients with lymphoedema are overweight or obese. Staff in one lymphoedema service aimed to help patients reduce weight through a course designed to emphasise a pyschological approach to weight management
- Psychological health is key to physical health and wellbeing
- Peer support is essential in weight loss, and, if consistent, significantly impacts on successful outcomes
- Sustained patient engagement and volition supports the addressing of barriers to weight loss and practising self-control/regulation strengthens self-control in the long term
CPD reflective questions
- Think about the psychological impact of obesity on individuals and families
- Consider the assessment of lymphoedema/chronic oedema in individuals who are obese
- What influence does obesity have on achieving positive outcomes from lymphoedema/chronic oedema management?
- Reflect on your own personal practice in assessing and managing individuals with obesity and lymphoedema